Unidirectional barbed sutures vs. interrupted intracorporeal knots in thoracoscopic repair of congenital diaphragmatic hernia in pediatrics.

Background: Intracorporeal suturing knots continue to be one of the most challenging and time-consuming steps in the thoracoscopic repair of congenital diaphragmatic hernia (CDH). Barbed unidirectional knotless sutures are designed to shorten surgical procedures by eliminating the need to tie knots. This work aimed to compare unidirectional barbed sutures and interrupted intracorporeal knots in the thoracoscopic repair of CDH in pediatrics regarding the time required to suture, operative time and complications. Methods: This retrospective study included 139 patients presented with Bochdalek CDH. Patients were classified into early (neonatal) and late presentations. The hernia defect was repaired by unidirectional Barbed sutures (V-LocTM and StratafixTM sutures) in group B or by Conventional interrupted intracorporeal knots in group C. Results: In both early and delayed presentations, the time required to suture (15 and 13 min in group B, 33 and 28 min in group C for neonatal and delayed presentation respectively) was significantly shorter in group B. Complications (visceral perforation, wound infection, and recurrence) insignificantly differed between group B and group C of early presentation. No patients suffered from major complications in both groups. Conclusions: Both unidirectional barbed sutures and intracorporeal knots were safe and effective. However, unidirectional barbed sutures are a time-saving choices for CDH thoracoscopic repair in early and late presentations.

Pectoral nerve blocks for transvenous subpectoral pacemaker insertion in children: a randomized controlled study.

BACKGROUND: Postoperative pain management after pacemaker insertion routinely requires opioid agents, nonsteroidal anti-inflammatory drugs, or paracetamol. However, interest in opioid-sparing multimodal pain management to minimize postoperative narcotic use has increased recently. This study aimed to assess the pectoral nerve (PECS) block versus standard treatment on postoperative pain control and opioid consumption in pediatric patients after transvenous subpectoral pacemaker insertion. METHODS: In this randomized controlled study, 40 pediatric patients underwent transvenous subpectoral pacemaker insertion with either congenital or postoperative complete heart block. Patients were randomly assigned to two groups: Group C (control) received conventional analgesic care without any block and Group P (pectoral) received a PECS block. Demographics, procedural variables, postoperative pain, and postoperative opioid consumption were compared between the two groups. RESULTS: In children undergoing transvenous subpectoral pacemaker insertion, the PECS block was associated with a longer procedure time; however, the cumulative dose of fentanyl and atracurium was reduced and the hemodynamic profile was superior in Group P compared with Group C intraoperatively. Postoperatively, the PECS block was associated with lower postprocedural pain scores, which was reflected by the longer interval before the first call for rescue analgesia and lower postoperative morphine consumption, without an increase in the rate of complications. CONCLUSION: Ultrasound-guided PECS blocks are associated with a good intraoperative hemodynamic profile, reduced postoperative pain scores, and lower total opioid consumption in children undergoing transvenous subpectoral pacemaker placement.

Congenital aflatoxicosis, mal-detoxification genomics & ontogeny trigger immune-mediated Kotb disease biliary atresia variant: SANRA compliant review.

Biliary atresia (BA) is the most common indication for pediatric liver transplantation. We describe The BA variant: Kotb disease. Liver tissue in the Kotb disease BA is massively damaged by congenital aflatoxicosis resulting in inflammation, adhesions, fibrosis, bile duct proliferation, scarring, cholestasis, focal syncytial giant cell transformation, and typical immune response involving infiltration by CD4+, CD8+, CD68+, CD14+, neutrophil infiltration, neutrophil elastase spill, heavy loads of aflatoxin B1, accelerated cirrhosis, disruption of p53 and GSTPi, and have null glutathione S transferase M1 (GSTM1). All their mothers are heterozygous for GSTM1. This inability to detoxify aflatoxicosis results in progressive inflammatory adhesions and obliterative cholangiopathy early in life. The typical disruption of both p53 and GSTPi causes loss of fidelity of hepatic regeneration. Hence, regeneration in Kotb disease BA typically promotes accelerated cirrhosis. The immune response in Kotb disease BA is for damage control and initiation of regeneration, yet, this friendly fire incurs massive structural collateral damage. The Kotb disease BA is about actual ongoing hepatic entrapment of aflatoxins with lack of ability of safe disposal due to child detoxification-genomics disarray. The Kotb disease BA is a product of the interaction of persistent congenital aflatoxicosis, genetic lack of GSTM1 detoxification, ontogenically impaired activity of other hepatic detoxification, massive neutrophil-elastase, immune-induced damage, and disturbed regeneration. Ante-natal and neonatal screening for aflatoxicosis, avoiding cord milking, and stringent control of aflatoxicosis content of human, poultry and live-stock feeds might prove effective for prevention, prompt diagnosis and management based on our recent understanding of its patho-genomics.

Effect of Ventilation Strategy During Cardiopulmonary Bypass on Arterial Oxygenation and Postoperative Pulmonary Complications After Pediatric Cardiac Surgery: A Randomized Controlled Study.

OBJECTIVES: To compare the effects of 3 ventilation strategies during cardiopulmonary bypass (CPB) on arterial oxygenation and postoperative pulmonary complications (PPCs). DESIGN: A prospective, randomized, controlled study. SETTING: A single-center tertiary teaching hospital. PARTICIPANTS: One hundred twenty pediatric patients undergoing elective repair of congenital acyanotic heart diseases with CPB. INTERVENTIONS: Patients were assigned randomly into 3 groups according to ventilation strategy during CPB as follows: (1) no mechanical ventilation (NOV), (2) continuous positive airway pressure (CPAP) of 5 cmH2O, (3) low tidal volume (LTV), pressure controlled ventilation (PCV), respiratory rate (RR) 20-to-30/min, and peak inspiratory pressure adjusted to keep tidal volume (Vt) 2 mL/kg. MEASUREMENTS AND MAIN RESULTS: The PaO2/fraction of inspired oxygen (FIO2) ratio and PaO2 were higher in the 5 minutes postbypass period in the LTV group but were nonsignificant. The PaO2/FIO2 ratio and PaO2 were significant after chest closure and 1 hour after arrival to the intensive care unit with a higher PaO2/FIO2 ratio and PaO2 in the LTV group. Regarding the oxygenation index, the LTV group was superior to the NOV group at the 3 time points, with lower values in the LTV group. There were no significant differences in the predictive indices among the 3 groups, including the extubation time, and postoperative intensive care unit stays days. The incidence of PPCs did not significantly differ among the 3 groups. CONCLUSIONS: Maintaining ventilation during CPB was associated with better oxygenation and did not reduce the incidence of PPCs in pediatric patients undergoing cardiac surgery.

Laparoscopic management of infantile hydrocele in pediatric age group.

PURPOSE: To evaluate laparoscopic management of hydroceles in pediatrics, with evaluation of the internal inguinal ring (IIR) and the PPV (patent processus vaginalis) in different types of hydroceles, and the incidence of the contralateral PPV. METHODS: The IIR and the type of hydrocele on the same side of 93 patients with 106 infantile hydroceles were evaluated and managed, in addition to contralateral side. RESULTS: The IIR on same side was closed in 8.5% (Type I) and patent in 91.5% (Type II and III) with different shapes. Contralateral IIR was open in 88.7% of cases. The operative time was 30.99 ± 7.23 min, with no intra-operative complication. The vas deferens and testicular vessels were secured and there were no injuries or bleeding. The conversion rate was zero, and all procedures (Type II and II) were completed totally laparoscopic. No post-operative complications except a case of tense hydrocele developed scrotal edema that managed conservatively. CONCLUSION: Laparoscopic hydrocelectomy is safe, applicable and feasible for management of different types of hydroceles in pediatrics. The IIR is patent in nearly all cases with/out communication to the hydrocele. The contralateral IIR can be managed in the same session. Laparoscopic hydrocelectomy with/out hydrocelectomy and IIR closure is essential in preventing recurrence.

The Effect of Antrum Size on Weight Loss, Glucagon-Like Peptide-1 (GLP-1) Levels, and Glycemic Control Following Laparoscopic Sleeve Gastrectomy in Adolescents with Obesity and Type 2 Diabetes.

PURPOSE: The aim of this study was to compare the effect of antral resection versus antral preservation sleeve gastrectomy on the post-operative GLP-1, glycemic control, and weight loss in adolescents suffering from severe obesity and type 2 diabetes (T2D). MATERIALS AND METHODS: This study included 36 adolescents. Patients were randomly divided into 2 groups: group (A) and group (B). Each group included 18 patients who underwent LSG, starting transection at 2 cm or 5 cm from the pyloric ring in group (A) and group (B), respectively. They were followed up at 1, 3, 6, 12, and 24 months post-operatively. The outcomes were the post-operative GLP-1 response, glycemic control, weight loss, and safety. RESULTS: The improvements in the body mass index and the percentage of excess weight loss (%EWL) were statistically significant within each group. The mean GLP-1 levels showed significant increase at the 1, 3, and 6 months but not in the 12 and 24 months in all the studied samples within each group. The mean HbA1c levels and post-prandial serum C-peptide significantly improved within each group (P < 0.05). No statistical differences in the weight loss, %EWL, GLP-1, HbA1c, C-peptide changes, and complication rates were observed between both groups. Diabetic remission was significantly higher (88.9%) in group (A). CONCLUSIONS: LSG resulted in generalized significant GLP-1 initial response that decreased over time. The reduced antrum size did not influence the GLP-1 response, glycemic control, or insulin resistance, but resulted in significantly better T2D remission. Since the study examines a small number of patients, further studies are needed. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04388059.

Advances in Brain Imaging Techniques for Patients With Intractable Epilepsy.

Intractable epilepsy, also known as drug resistance or refractory epilepsy, is a major problem affecting nearly one-third of epilepsy patients. Surgical intervention could be an option to treat these patients. Correct identification and localization of epileptogenic foci is a crucial preoperative step. Some of these patients, however, have no abnormality on routine magnetic resonance imaging (MRI) of the brain. Advanced imaging techniques, therefore, can be helpful to identify the area of concern. Moreover, a clear delineation of certain anatomical brain structures and their relation to the surgical lesion or the surgical approach is essential to avoid postoperative complications, and advanced imaging techniques can be very helpful. In this review, we discuss and highlight the use of advanced imaging techniques, particularly positron emission tomography (PET)-MRI, single-photon emission computed tomography, functional MRI, and diffusion tensor imaging-tractography for the preoperative assessment of epileptic patients.

Homemade Glove Retrieval Bag in Laparoscopic Complete Excision of Benign Ovarian Teratoma with Ovarian Tissue Preservation in Children: A Case Series.

STUDY OBJECTIVE: To present our experience of laparoscopic resection of pediatric benign ovarian teratomas with gonadal preservation, using a homemade glove retrieval bag. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: Review of all girls with benign ovarian teratomas who were managed with laparoscopic ovarian-sparing surgery (OSS) at our hospital between January 2013 and December 2018. RESULTS: Eleven patients were included for analysis with a mean age of 6.1 years. Ten patients received elective surgery, whereas 1 patient received emergency surgery because of ovarian torsion. Main indication for OSS was the existence of a dissection plane between tumor margins and healthy ovarian tissue. Postoperative outcome and follow-up were uneventful with a median follow-up of 30.1 months (range; 12-60 months). CONCLUSION: Laparoscopic OSS can be safely performed for these tumors. Laparoscopic magnification with energy devices are excellent tools in such procedures. The homemade glove bag can be used to retrieve the tumor effectively in countries with limited resources.

Frequency of hepatitis B and C in health care providers at three referral hospitals in Libya.

INTRODUCTION: the aim of the present study was to determine the frequency of HBsAg and anti-HCV antibodies in health care providers (HCPs) at three referral hospitals in Libya, and to correlate the HBsAg status with history of hepatitis B vaccination among HCPs. METHODS: one hundred eighty-two HCPs, with a mean age (±SD) of 32.9±8 years and age range from 20 to 59 years, were enrolled in this study. They were 50 doctors, 68 nurses, 42 laboratory technicians, 12 hospital cleaners, five anesthesia technicians and five midwives. They were tested, after obtained a written consent, for the presence of HBsAg and anti-HCV antibodies by enzyme linked immuno-sorbent assay (ELISA) techniques. A pre-test questionnaire was filled by each HCP to verify place of work, working period, type of work, status of HBV vaccination, and history of needle stick injury. RESULTS: four HCPs have anti-HCV antibodies positive (2.2%) and nine were HBsAg positive (4.9%). Only 52% (95/182) of the HCPs received full dose of hepatitis B vaccine, while the others either not completed the vaccination schedule or have not receive it. One hundred (54.9%) of the participants had exposed to blood via needle stick injury during their work, 6 (6%) of them were HBsAg positive and three (3%) were anti-HCV positive. Needle stick injury was considered as primary risk factor in 66.7% (6/9 HCPs) of HBsAg-positives and 75% (3/4 subjects) of anti-HCV-positives. CONCLUSION: the present study showed a higher frequency of HBsAg than anti-HCV among HCPs in three major hospitals in Libya. This difference may be explained by the low hepatitis B vaccination rate and the high rate of needle stick injury among this high risk group for these infections.

Minimally Invasive Surgery for Pediatric Adrenal Masses-Report on Four Cases.

The dignity of adrenal masses in children varies from benign lesions like adenoma and ganglioneuroma to malignant tumors like adrenocortical carcinoma and neuroblastoma. Any surgical approach, especially minimally invasive surgery (MIS), requires careful risk stratification based on oncological and technical criteria. Herein, we present four patients who underwent MIS for adrenal masses. Laboratory testing differentiated between simple cysts and adenoma, but could not identify a child with adrenocortical tumor preoperatively. Analysis of image-defined risk factors excluded vascular encasement in all cases. All patients underwent laparoscopic adrenalectomy without complications. Histopathology revealed simple cyst, ganglioneuroblastoma, adenoma, and potentially malignant adrenocortical tumor in one patient/case each. All specimen showed clear margins and no recurrence was noted at a mean follow-up of 18 months.

Laparoscopic Posterolateral Suture Rectopexy for Recurrent Rectal Prolapse in Children.

Introduction: Laparoscopic rectopexy for recurrent rectal prolapse (RP) is more widely used nowadays. Strict indications are needed to get proper outcomes. The advantages rely on the careful dissection of peritoneal sac and fixation of rectum. One of the theories of recurrent RP is hernia-like physiology in front of the rectum. Purpose: The aim of this study is to present our experience of posterolateral laparoscopic suture rectopexy (LSR) in indicated children of recurrent RP. Patients and Methods: Sixteen patients were included with recurrent RP wherein all were subjected to LSR procedure after exclusion of other probable causes. Dissection of peritoneal sac anterior to the rectum was carried out followed by closure of the deep pouch by nonabsorbable sutures then fixation of the right side of rectum and sigmoid to the lateral wall of areolar tissue. Fixation to sacral promontory is done by Ethibond or Prolene sutures when redundancy is obvious. Results: The study included 11 girls and 5 boys with age ranging between 3 and 12 years in the past 5 years. Ten cases were treated earlier with injection therapy and 6 following Thiersh procedure after failure of conservative treatment for 6 months. Operative time ranged between 40 and 100 minutes. Follow-up period ranged between 6 and 36 months with mean of 19.5 months. Postoperative mucosal prolapse reported in 1 case 6 months postsurgery with no full thickness recurrence. Conclusions: LSR is an efficient technique in well-selected children of recurrent RP and could reverse this underlying pathology. Longer follow-up and evidence are needed to standardize the technique.

Laparoscopic Distal Pancreatectomy of a Solid Pseudopapillary Tumor (SPT) Achieves Long-Term Oncologic Safety and Multiorgan Preservation.

The oncological safety of a laparoscopic approach for solid pseudopapillary tumors (SPTs) of the pancreas remains a matter of debate. We present the long-term follow-up of an adolescent girl with an SPT in the pancreatic tail. A multimodality workup including magnetic resonance imaging (MRI) revealed a complex, spherical mass of 4.4 cm × 3.6 cm × 4 cm most likely located in the pancreatic tail. All routine laboratory investigations and tumor markers were within normal limits (alpha fetoprotein [AFP], cancer antigen 125 [CA125], CA 19-9, carcinoembryonic antigen [CEA], adrenocorticotropic hormone [ACTH]). Diagnostic laparoscopy was performed to verify the origin of the tumor in the pancreatic tail. In a three-port technique the tumor was mobilized of the splenic vessels until a distal pancreatectomy could be completed. Histopathological examination confirmed the complete resection of a low-grade malignant SPT. The postoperative course was unremarkable. Regular pediatric oncological follow-up examinations for 3 years, including MRI every 6 months, ruled out recurrence and confirmed preservation of splenic and pancreatic functions. While data about the technical feasibility of a laparoscopic approach to pancreatic SPT are already available, this pediatric case report adds a long-term oncological and functional success to the available literature.

Microbial Evidence in Congenital Pulmonary Airway Malformations of Young Asymptomatic Infants.

Introduction: Experts of pediatric endosurgery recommend early thoracoscopic resection of congenital pulmonary airway malformations (CPAM) even in asymptomatic infants due to the risk of later infections. However, neither the rate of lower airway inflammation nor the underlying microbes and their pathogenic potential have been revealed in CPAMs yet. Using latest gene-sequencing techniques, we present the first study analyzing the pulmonary microbiome in young asymptomatic infants with CPAM. Materials and Methods: Seven asymptomatic infants (age 2-3 months) underwent thoracoscopic lobectomy for CPAM. Preoperatively, blood test was taken to rule out systemic infections. Surgical specimen was screened and graded for local inflammation by hematoxylin and eosin (HE) histology. The pulmonary microbiome and mycobiome were assessed using next-generation sequencing. Results: Preoperatively, all infants had normal white blood cell counts and normal C-reactive protein (CRP) levels. Microbial evidence was found in 4/7 patients, 3 being bacteria (Pseudomonas twice, Streptococcus sp. once) and 1 fungal species (Pneumocystis jirovecii, mostly known from immunosuppressed patients, and Preussia funiculata). Histologically, both Pseudomonas and fungi were associated with low and intermediate pulmonary inflammation, whereas Streptococcus was negative for leucocyte infiltration. Conclusion: For the first time ever this study revealed genetic evidence of pathogenic microbes in 4/7 CPAMs causing lower airway inflammation in 3/7 asymptomatic young infants. Especially pseudomonas and fungi represent considerable pathogenic potential and call for a broader, age-dependent, multicenter study of CPAMs. Such data could be important for pediatric surgeons counseling parents about the necessity and timing of thoracoscopic resections.

The effects of neuroblastoma and chemotherapy on metabolism, fecal microbiome, volatile organic compounds, and gut barrier function in a murine model.

BACKGROUND: Following transplantation of human neuroblastoma (NB) cells into athymic mice, we investigated the effects of tumor growth and cyclophosphamide (CTX) treatment on systemic metabolism, gut inflammation and permeability, fecal microbiome and volatile organic compounds (VOCs). METHODS: NB cells (MHH-NB11) were implanted into athymic mice (n=20); 20 healthy mice served as controls (sham).  CTX was given to 20 animals (10 NB and 10 sham) after 8 and 9 weeks. Metabolic changes were measured. Ileum samples were obtained for RT-PCR (claudins 2 and 4, occludin, tight junction protein 1) and apoptosis rate determination. Fecal microbiome and VOCs were analyzed. Values were compared to sham animals. RESULTS: NB caused reduction of adipose tissue, increases of IL-6 and TNF-α, and decreases of TGF-ß1 and -ß2. Serum FITC-dextrane levels were increased in NB and improved under CTX. Claudin 4 expression was higher in NB versus NB + CTX and sham animals. NB caused increased apoptosis of epithelial cells. NB but also CTX led to a reduction in the abundance of Lactobacillus. NB led to alterations of the fecal VOC profile. CONCLUSIONS: NB caused a catabolic pro-inflammatory state, increased gut permeability, altered fecal VOCs and reductions of Lactobacillus. Further investigations are required to determine if modifications of the intestinal microbiome may reverse some of the observed effects.

Laparoscopic posterior rectopexy (Well's procedure) for full-thickness rectal prolapse following laparoscopic repair of an anorectal malformation: A case report.

INTRODUCTION: Intractable full-thickness rectal prolapse (IRP) unresponsive to conservative treatment remains a major problem after anorectoplasty for high or intermediate anorectal malformation (ARM). Surgical management must aim for a permanent fixation of the rectum to the presacral fascia. While in children with IRP following ARM repair the optimal procedure has not been established yet, laparoscopic posterior mesh-rectopexy (Well's procedure) has demonstrated efficacy in adults. PRESENTATION OF CASE: A male infant with intermediate ARM received laparoscopic-assisted anorectal pull-through at the age of 4 months. Three months later he developed mucosal prolapse and received multimodal conservative treatment. Because of progression into a full-thickness RP with ulcerations, the parents opted for surgical management. Well's procedure was performed at the age of 4 years. Using four ports, the rectum was circumferentially mobilized down to the pelvic floor and pulled inside. A 5 × 5 cm prolene mesh was tacked to the sacrum, enveloped posteriorly 270° around the rectum, fixed with interrupted prolene sutures on both edges and carefully covered with peritoneum. Any redundant external mucosa was excised from a perineal approach. There were no intra- and postoperative complications. Within 1.5 years of follow-up the boy had voluntary bowel movements and was toilet trained. No prolapse recurrence could be observed nor provoked. DISCUSSION: We present the first pediatric case of IRP secondary to laparoscopic ARM repair which has been successfully treated by combined Well's procedure and perineal mucosal resection. CONCLUSION: Well's procedure is a successful technique and should be further explored in children with ARM and IRP.

The effect of antipyretic therapy upon outcomes in critically ill patients: a randomized, prospective study.

BACKGROUND: Despite the large body of evidence suggesting a beneficial role of fever in the host response, antipyretic therapy is commonly employed for febrile critically ill patients. Our objective was to evaluate the impact of antipyretic therapy strategies on the outcomes of critically ill patients. METHODS: Patients admitted to the Trauma Intensive Care Unit over a nine-month period were eligible for inclusion, except those with traumatic brain injury. Patients were randomized on day three of the ICU stay into aggressive or permissive groups. The aggressive group received acetaminophen 650 mg every 6 h for temperature of >38.5 degrees C and a cooling blanket was added for temperature of >39.5 degrees C. The permissive group received no treatment for temperature of >38.5 degrees C, but instead had treatment initiated at temperature of >40 degrees C, at which time acetaminophen and cooling blankets were used until temperature was <40 degrees C. Patient demographics, daily temperatures, systemic inflammatory response syndrome (SIRS) scores, multiple organ dysfunction syndrome (MODS) scores, and infections and complications were recorded. RESULTS: Between December, 2002 and September, 2003, 572 patients were screened, of whom 82 met criteria for enrollment. Forty-four patients were randomized to the aggressive group and 38 patients were randomized to the permissive group for a total of 961 and 751 ICU days, respectively. There were 131 infections in the aggressive group and 85 infections in the permissive group (4 +/- 6 vs. 3 +/- 2 infections per patient, p = 0.26). There were seven deaths in the aggressive group and only one death in the permissive group (p = 0.06, Fisher Exact Test). The study was stopped after the first interim analysis due to the mortality difference, related to the issues of waiver of consent and the mandate for minimal risk. CONCLUSIONS: Aggressively treating fever in critically ill patients may lead to a higher mortality rate.